Faculty Bibliography

OBJECTIVE:The insufficient diagnostic accuracy for differentiation between benign and malignant adrenocortical disease and lack of sensitive markers reflecting tumor load emphasize the need for novel biomarkers for diagnosis and follow-up of adrenocortical carcinoma (ACC). DESIGN/METHODS:Since the inhibin α-subunit is expressed within the adrenal cortex, the role of serum inhibin pro-αC as a tumor marker for ACC was studied in patients. METHODS:Regulation of adrenal pro-αC secretion was investigated by adrenocortical function tests. Serum inhibin pro-αC levels were measured in controls (n=181) and patients with adrenocortical hyperplasia (n=45), adrenocortical adenoma (ADA, n=32), ACC (n=32), or non-cortical tumors (n=12). Steroid hormone, ACTH, and inhibin A and B levels were also estimated in patient subsets. RESULTS:Serum inhibin pro-αC levels increased by 16% after stimulation with ACTH (P=0.043). ACC patients had higher serum inhibin pro-αC levels than controls (medians 733 vs 307 ng/l, P<0.0001) and patients with adrenocortical hyperplasia, ADA, or non-adrenocortical adrenal tumors (148, 208, and 131 ng/l, respectively, P=0.0003). Inhibin pro-αC measurement in ACC patients had a sensitivity of 59% and specificity of 84% for differentiation from ADA patients. Receiver operating characteristic analysis displayed areas under the curve of 0.87 for ACC vs controls and 0.81 for ACC vs ADA (P<0.0001). Surgery or mitotane therapy was followed by a decrease of inhibin pro-αC levels in 10/10 ACC patients tested during follow-up (P=0.0065). CONCLUSIONS:Inhibin pro-αC is produced by the adrenal gland. Differentiation between ADA and ACC by serum inhibin pro-αC is limited, but its levels may constitute a novel tumor marker for ACC.

Incentives for organ donation, currently prohibited in most countries, may increase donation and save lives. Discussion of incentives has focused on two areas: (1) whether or not there are ethical principles that justify the current prohibition and (2) whether incentives would do more good than harm. We herein address the second concern and propose for discussion standards and guidelines for an acceptable system of incentives for donation. We believe that if systems based on these guidelines were developed, harms would be no greater than those to today's conventional donors. Ultimately, until there are trials of incentives, the question of benefits and harms cannot be satisfactorily answered.

The placenta functions to nourish and protect the fetus. Imaging of the placenta can have a profound impact on patient management, owing to the morbidity and mortality associated with various placental conditions. To fully appreciate placental pathology, its physiology, anatomy, and variant anatomy will be outlined. Placental conditions affecting the mother and fetus include molar pregnancies, placental hematoma, abruption, previa, accreta, vasa previa, choriocarcinoma, and retained products of conception. Ultrasonography remains the definitive modality in diagnosing most of these conditions, with magnetic resonance imaging remaining an adjunctive measure. Computed tomography is occasionally used in cases of trauma and tumor staging.

BACKGROUND:Quality improvement (QI) initiatives reduce medical errors and are an important aspect of resident physician training. Many institutions have limited funding and few QI experts, making it essential to develop effective programs that require only modest resources. We describe a resident-led, hospitalist-facilitated limited root cause analysis (RCA) QI program developed to meet training needs and institutional constraints. METHODS:We initiated a monthly quality improvement conference (QIC) at the Mount Sinai Hospital in New York City, New York. Before each conference, a third-year resident investigated a patient care issue and completed a limited RCA. At the QIC, the findings were presented to the Internal Medicine residents, followed by a chief resident and hospitalist-facilitated group discussion. All proposed interventions were recorded, and selected interventions were later implemented. The success of these interventions in achieving permanent system-wide change or resident behavior change was tracked. Residents' views on the conferences were solicited via an anonymous questionnaire. RESULTS:Twenty conferences were held over the first 22 months of the program. Twenty-five (54%) of the 46 suggested interventions were initiated. Eighteen (72%) attempted interventions resulted in system-wide change or resident behavior change. Fifty-three residents evaluated the quality of the conferences. The majority believed the conferences were high quality (98%) and led to patient care improvements (96%). CONCLUSIONS:Resident-led modified RCAs are an effective method of integrating QI efforts into resident training. As front line providers, residents are uniquely positioned to identify and implement system changes that benefit patients. Conferences were implemented without overburdening facilitators or participants.

Grey's Anatomy [Television Program] -- After watching her father suffer multiple cardiac arrests, Lily asks Meredith to stop using heroic measures to revive him. Since it is her 18th birthday and she is a legal adult, the doctors follow her wishes.

The early days In June 2009, when President Obama attended a "white coat" ceremony at the American Medical Association headquarters in Chicago, and this organization of physicians (roughly 17% are members) went on to deliver its endorsement of the president's legislation, physicians had a nagging question: [...] the law does the opposite:

The utility of human pluripotent stem cells is dependent on efficient differentiation protocols that convert these cells into relevant adult cell types. Here we report the robust and efficient differentiation of human pluripotent stem cells into white or brown adipocytes. We found that inducible expression of PPARG2 alone or combined with CEBPB and/or PRDM16 in mesenchymal progenitor cells derived from pluripotent stem cells programmed their development towards a white or brown adipocyte cell fate with efficiencies of 85%-90%. These adipocytes retained their identity independent of transgene expression, could be maintained in culture for several weeks, expressed mature markers and had mature functional properties such as lipid catabolism and insulin-responsiveness. When transplanted into mice, the programmed cells gave rise to ectopic fat pads with the morphological and functional characteristics of white or brown adipose tissue. These results indicate that the cells could be used to faithfully model human disease.

Carnage [Motion Picture] -- The reality Though the film identifies Zachary as the bully, Ethan has also engaged in bullying behavior by helping to initiate and escalate -- rather than resolve -- their conflict, says Jaana Juvonen, a professor of developmental psychology and bullying expert at UCLA.

The 2008 Physical Activity (PA) Guidelines recommend engaging in at least 2.5 h (10 MET-hours/week) of moderate intensity PA per week (defined as 4 METs) to reduce risk of morbidity and mortality. This analysis was conducted to investigate whether this recommendation can be extended to breast cancer survivors. Data from four studies of breast cancer survivors measuring recreational PA from semi-quantitative questionnaires a median of 23 months post-diagnosis (interquartile range 18-32 months) were pooled in the After Breast Cancer Pooling Project (n = 13,302). Delayed entry Cox proportional hazards models were applied in data analysis with adjustment for age, post-diagnosis body mass index, race/ethnicity, menopausal status, TNM stage, cancer treatment, and smoking history. Engaging in at least 10 MET-hours/week of PA was associated with a 27% reduction in all-cause mortality (n = 1,468 events, Hazard Ratio (HR) = 0.73, 95% CI, 0.66-0.82) and a 25% reduction in breast cancer mortality (n = 971 events, HR = 0.75, 95% CI 0.65-0.85) compared with women who did not meet the PA Guidelines (<10 MET-hours/week). Risk of breast cancer recurrence (n = 1,421 events) was not associated with meeting the PA Guidelines (HR = 0.96, 95% CI, 0.86-1.06). These data suggest that adhering to the PA guidelines may be an important intervention target for reducing mortality among breast cancer survivors.